Dr. Scholer educated us on many of the facets of obesity management in adult patients today.
What do I need to know about weight loss to counsel my patients?
First, let them know that a major weight loss isn't needed for health benefits. Health benefits are usually apparent after only 5% loss body weight.
Be realistic with patients when setting goals based on the type of interventions you are using. For instance, lifestyle modifications usually result in 5-7% loss of body weight but most patients have goal weight loss 30% or more of their current weight. This is generally not achievable without bariatric surgery.
What are lifestyle modifications?
When discussing lifestyle modifications with patients, make sure to address that dietary modifications are the MOST important component of weight loss ("You can't outrun your fork").
There are literally hundreds of diets programs out there (paleo, intermittent fasting, keto, South Beach, Atkins, etc.)!
The program that a patient chooses doesn't matter, as long as they stick to it. Additionally, discuss caloric restriction with patients and that a caloric deficit is at the core of all dietary programs. Nutrition referral can be helpful for patients who are interested. Behavioral modification (i.e. controlling triggers that cue the patient to eat more) need to be discussed as well.
Exercise is also a key component but it alone cannot result in substantial weight loss. There are literally hundreds of exercise programs out there (think of the BeachBody MLM!). In general, your advice for exercise should be the same: pick something that the patient can stick to long term. You should advise 30 minutes or more of physical activity, 5-7 days a week.
When do I use medications for weight loss?
Consider for patients who meet the following:
BMI > 30
BMI 27-29 with comorbidities
Failure to meet weight loss goal of 5% body weight over 3-6 months
Lorcaserin is a medication that activates 5HT2 receptors, ultimately leading to increased early satiety and decreased food intake. it ay be used in patients with/without diabetes who have cardiovascular disease or risk factors for cardiovascular disease. AVOID in patients on serotonergic agents! Increased risk of serotonin syndrome. It is also contraindicated in pregnancy.
Liraglutide (GLP-1 receptor agonist) can also be used for weight loss in patients with/without diabetes. The benefit is that it results in improved blood sugar control. However, there are significant GI side effects (nausea, vomiting), it requires daily injection, and insurance coverage/cost may limit use.
Orlistat is not first line treatment, but it has proven benefits with blood sugars, lipids, blood pressure in addition to weight loss. It works by resulting in fat malabsorption (think “oily stools”) and as such as significant GI side effects (diarrhea), which many patients cannot tolerate.
Phentermine-Topiramate can be considered for men or postmenopausal women without hypertension or coronary heart disease; generally, you can consider this if they haven’t tolerated other medications. Side effects include increased heart rate, dose-related increase in the incidence of depression, anxiety, and attention disturbance. Topiramate may increase risk of fetal malformations, so use with caution in women of childbearing age.
Combination Naltrexone-Bupropion has similar efficacy as Orlistat and Lorcaserin.
Contraindications include pregnancy, uncontrolled hypertension, seizure disorder, eating disorder.
When do I refer my patient for surgery?
Consider for patients who meet the following:
BMI ≥40 kg/m2
BMI of 35 to 39.9 kg/m2 with at least one serious comorbidity, who have not met weight loss goals with diet, exercise, and drug therapy
What are the surgical options?
Gastric banding (Purely restrictive)
Roux-en-Y (Both restrictive and malabsorptive)
Sleeve gastrectomy (Purely restrictive)
References
Leigh Perrault, M.D.; Caroline Apovian, M.D. Obesity in adults: Overview of management. September 2019. UpToDate
Leigh Perrault, M.D. Obesity in adults: drug therapy. November 2019. UpToDate
Robert B Lim, M.D. Bariatric procedures for the management of severe obesity. September 2019. UpToDate
Leigh Perrault, M.D. Obesity in adults: Etiology and risk factors. September 2019. UpToDate
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